This working paper was discussed at the Council's December 2005 meeting. It was prepared by staff solely to aid discussion, and does not represent the official views of the Council or of the United States Government.

Staff Working Paper

Bioethics and Human Dignity
By Adam Schulman, Ph.D.
Senior Research Consultant

“Human dignity”: is it a useful concept in bioethics, one that sheds important light on the whole range of bioethical issues, from embryo research and assisted reproduction, to biomedical enhancement, to care of the disabled and the dying? Or is it, on the contrary, a useless concept—at best a vague substitute for other, more precise notions, at worst a mere slogan that camouflages unconvincing arguments and unarticulated biases?

Although the Council has itself made frequent use of this notion in its writings, it has not undertaken a thematic exploration of human dignity, its meanings, its foundations, and its relevance for bioethics. In the meantime, at least one critic, noting that “appeals to human dignity populate the landscape of medical ethics,” has recently called into question whether human dignity has any place in bioethical discourse at all.¹ It would seem timely, then, for the Council to take up the question of human dignity squarely, with the aim of clarifying whether and how it might be a useful concept in bioethics.

The purpose of this working paper is to help the Council focus its discussion of human dignity and its proper place in bioethics. To that end, it will first give some examples of how human dignity can be a difficult concept to apply in bioethical controversies. It will then explore some of the complex roots of the modern notion of human dignity, in order to shed light on why its application to bioethics is so problematic. Finally, it will suggest, tentatively, that a certain conception of human dignity—dignity understood as humanity—has an important role to play in bioethics, both now and especially in the future.

1. The problem of human dignity in bioethics: some examples

That human dignity might be at least problematic as a bioethical concept is suggested by the many ways it gets invoked in bioethical debates, often on different sides of the same issue. Consider, for example, a question raised in the Council’s recent exploration of ethical caregiving at the end of life:² Is it morally acceptable for an elderly patient, diagnosed with early Alzheimer’s disease and facing an inexorable decline into dementia and dependency, to stop taking his heart medicine, in the hope of a quicker exit, one less distressing to himself and his family? One possible answer discussed in our report is that it is morally permissible (and perhaps even admirable) for such a patient, who finds the prospect of years of dementia humiliating or repellent and who is reluctant to become a burden to his family, to forgo medication and allow heart disease to carry him off in a more dignified and humane way. Another possible answer is that it is morally impermissible, because deliberately hastening the end of one’s life, even by an act of omission, is incompatible with the equal dignity and respect owed to all human life. A third answer is that respect for the dignity and autonomy of all persons requires us to defer to the personal choice of a competent individual in such intimate matters, regardless of how he or she might decide. Note that all three answers (and perhaps others that could be given) are grounded in part in some appeal to human dignity, though they reach quite different conclusions.

Or, to take an example from the beginning of human life, consider a question that might arise in a neonatal intensive care unit: What medical interventions are appropriate to save the life of a critically ill premature infant who is likely to survive, if at all, only with severe mental defects? One possible answer is that, because human dignity rests on our higher mental capacities, it is wrong to bring a person into the world burdened with a devastating lifelong mental incapacity. Another answer might be that every reasonable measure should be taken, because the equal dignity of all human life forbids us to declare some lives “not worth living.” Yet a third answer might be that, out of respect for their dignity and autonomy, the parents must be left free to resolve this moral dilemma for themselves.

Or, again, consider an example of biomedical “enhancement” examined in the fifth chapter of Beyond Therapy:³ If science were to develop memory-blunting drugs that could free us from the emotional burdens of intrusive and painful memories, would it be ethically permissible to give such drugs freely to people who have suffered grievous disappointments or witnessed horrifying events? One answer might be that such an invention, with its promise of liberating miserable people from the emotional tyranny of past misfortunes, ought to be embraced as an unqualified enhancement to human freedom, autonomy, and dignity. But another answer might be that human integrity and dignity require of us that we confront our painful memories and learn to deal with them (if possible) and not just “flush” them away by taking a pill. A third answer would be that this decision is properly left to the individual, whose dignity and autonomy entail the right of voluntary, informed consent.

In each of these examples, a variety of strong convictions can be derived from powerful but conflicting intuitions about what human dignity demands of us. Little wonder, then, that some bioethicists are inclined to wash their hands of “dignity” entirely, in favor of clearer and less ambiguous ethical concepts.

2. The tangled sources of human dignity

If human dignity seems a malleable concept of uncertain application in bioethics, that is partly because the idea of human dignity comes to bioethics from several disparate sources. Each of these sources contributes something of value for bioethics; yet each source also brings its own peculiar difficulties to the application of the concept of human dignity to bioethical controversies. At least four such sources of human dignity seem worth mentioning:

a. Classical antiquity: The word “dignity” comes to us, via the Latin dignus and dignitas, from Greek and Roman antiquity, in whose literature it means something like “worthiness for honor and esteem”. This classical notion of dignity as something rare and exceptional retains some of its power even in our egalitarian age: witness the admiration we bestow on outstanding athletic and musical performance, on heroism in war, on courageous statesmanship, or on the selflessness of those who make sacrifices or undergo hardships for the sake of their young children, or their aging parents, or their neighbors stricken by misfortune or tragedy. But if dignity implies excellence and distinction, then to speak of “human dignity” raises the question, what is it about human beings as such that we find distinctive and admirable, that raises them in our estimation above other animals? Is there some one attribute or capacity that makes man worthy of respect, such as reason, or conscience, or freedom? Or is it a complex of traits, no one of which is sufficient to earn our esteem? These are not easy questions to answer; yet most would acknowledge that there must be something about humankind that entitles us to the special regard implicit in this sense of human dignity.⁴

One problem with the classical notion of dignity that has only grown more acute in our age of rapid biomedical progress is the complicated relationship between technology and human dignity (understood as grounded in excellence). Is the dignity of the soldier enhanced by the invention of modern weapons? Is the dignity of the athlete enhanced by drugs that improve his performance, or even by his reliance on trainers, nutritionists, and other experts? Some might argue that new technologies (“bio” and otherwise) serve human dignity by augmenting those traits that make human beings worthy of esteem; yet others might view such inventions as undermining human dignity, by making our excellence depend too much on the artifice of others.

A second problem with dignity in its classical sense is that it lends itself to invidious distinctions between one human being and another; it is not fully at home in democratic times, where it keeps uneasy company with the more characteristic democratic ideals of equality, freedom, easygoingness, and tolerance.⁵ Now for that very reason one might argue that human dignity is especially vulnerable and worth defending in democratic times. But to make the case for human dignity as a robust bioethical concept for our age, one would have to show that dignity can be something universal and accessible to all human beings as such.

There was in fact a school of philosophy in ancient Greece and Rome, the Stoics, who believed in dignity as a genuine possibility for all human beings, regardless of their circumstances, social standing, or accomplishments. For the Stoics, human beings have dignity because they possess reason, and the best life, the life according to nature, is available to anyone who chooses to live in a thoughtful or reflective way. And what our reason dictates, above all, is that everything necessary for our happiness and peace of mind is within our control; despite poverty, illness, or oppression it is always possible to live in a dignified way. Nothing that anyone can say or do to you can rob you of your dignity and integrity. For the Stoics, dignity is a profoundly democratic idea, in that it is just as likely to be found among the wretched as among the lofty: as possible for the slave Epictetus as for the emperor Marcus Aurelius.⁶

Yet while dignity as the Stoics conceived it is a universal possibility for all human beings everywhere, it nonetheless sets a rigorous and exacting standard that few of us, in practice, manage to attain. And while the Stoic teaching of indifference to bodily suffering might well prove to be a valuable discipline for those who have to live with pain, illness, or infirmity, the Stoic attitude of detachment from the things of this world—embodied in the principle that “nothing that can be taken from you is good”—means that particular bioethical questions are ultimately of little significance from the Stoic point of view.

b. Biblical religion: Another powerful source of a broader, shared notion of human dignity is the Biblical account of man as “made in the image of God.” This teaching, together with its further elaborations in Jewish and Christian scripture, has been interpreted in many different ways, but the central implication seems to be that human beings, because they are in some respects godlike, possess an inherent and inalienable dignity. One part of that dignity, suggested by the Book of Genesis, has to do with the special position of man in the natural world: within that realm man is like God in having stewardship or dominion over all things, because he alone can comprehend the whole and he alone concerns himself with the good of the whole.⁷ In this sense, “being made in God’s image” could even be taken to imply a special responsibility on our part to perfect nature in order to finish God’s creation. Interpreted in this way, the idea of human dignity could lend support not only to the practice of healing and medicine in general, but also, some might argue, to a defense of such activities as in vitro fertilization or even cloning, here understood as fixing nature in a godlike way.

Yet if man’s mastery of nature has some sanction in the Biblical teaching on human dignity, that teaching also points in another, humbler direction: for although made in God’s image, we are not ourselves divine; we are creatures, not creators. In this sense, “made in God’s image” has the implication that all human beings, not only those healthy and upright but also those broken in body or soul, have a share in this God-given dignity. Dignity in this sense would give ethical guidance to us in answering the question of what we owe to those at the very beginning of life, to those at the end, to those with severe disability or dementia, and even to tiny embryos. Seeing human beings as created in the image of God means, in some sense, valuing other human beings in the way a just or loving God would value them. It means seeing dignity where some might see only disability, and perhaps seeing human life where others might see only a clump of cells.

Yet because the Biblical account of human dignity points in different directions, its implications for bioethics are not always clear and unambiguous. In the controversy over stem cell research, for example, would the inherent dignity of man mean that human life at every stage is sacred, and that the destruction of human embryos is therefore forbidden? Or would it mean that healing and preserving human life is our preeminent duty, justifying all kinds of otherwise morally questionable research?

Some will argue that a concept of human dignity derived from the Bible (or other religious texts) is inherently unreliable, a mask for religious dogmas that have no legitimate place in secular bioethics. Thus Ruth Macklin, who advocates banishing the term “dignity” from medical ethics entirely, suspects that religious sources, especially Roman Catholic writings on human dignity, may explain why so many articles and reports appeal to human dignity “as if it means something over and above respect for persons or for their autonomy.”⁸ More recently, Dieter Birnbacher has suggested that the idea of human dignity, when invoked (as it has been in the cloning debate) to defend the natural order of human procreation against biotechnical manipulation, is nothing more than camouflage for a theological tradition that sees “the order of nature as divinely sanctioned.”⁹ Yet, while it might be problematic to rely on religious texts for authoritative guidance on bioethical questions, such texts may still be quite valuable in helping all of us—whether believers or not—to articulate and think through our deepest intuitions about human beings, their distinctive powers and activities, and the rights and responsibilities we believe them to possess. Furthermore, those who would dismiss all religious grounds for the belief in human dignity have the burden of showing, in purely secular terms, what it is about human beings that obliges us to treat them with respect. If not because they are “endowed by their Creator with certain unalienable rights,” then why are all men entitled to “life, liberty, and the pursuit of happiness”?¹⁰

c. Kantian moral philosophy: A daring attempt to set universal human dignity on a strictly rational foundation was made in the eighteenth century by the German philosopher Immanuel Kant. Kant’s primary purpose was to show how moral freedom and responsibility could still be possible in a world governed by the laws of mathematical physics. For Kant, in agreement with the Stoics, dignity is the intrinsic worth that belongs to all human beings and to no other beings in the natural world. All men possess dignity because of their rational autonomy, i.e., their capacity for free obedience to the moral law of which they themselves are the authors. Kant’s doctrine of human dignity demands equal respect for all persons and forbids the use of another person merely as a means to one’s own ends. Kant’s celebration of autonomy and his prohibition of the “instrumentalization” of human subjects have certainly had a lasting impact on modern ethical thought and on bioethics in particular (especially in the ethics of human experimentation and in the principle of voluntary, informed consent). And it cannot be denied that Kant’s account of what the moral law demands of us (his various formulations of “the categorical imperative”) has a certain austere majesty and logical economy that compel grudging respect if not wholehearted allegiance. Yet the application of Kant’s moral theory to bioethics remains problematic for a number of reasons.

First, Kant’s achievement in reconciling morality with mathematical physics was won at a great price: in locating human dignity entirely in rational autonomy, Kant was forced to deny any moral significance to other aspects of our humanity, including our family life, our loves, loyalties, and other emotions, as well as our way of coming into the world and all other merely biological facts about the human organism.¹¹ His exclusive focus on rational autonomy leaves Kant with a rather narrow and constricted account of our moral life, one that has precious little to say about the moral significance of a whole range of biomedical interventions that currently arouse ethical controversy. If the rational will alone is the seat of human dignity, why should it matter if we are born of cloned embryos, or if we enhance our muscles and control our moods with drugs, or if we sell our organs on the open market?

Second, the doctrine of rational autonomy itself, clear and unambiguous though it may be in theory, can be difficult to apply in practice, especially in a biomedical context. Consider these examples: If dignity depends on the rational will, must we conclude that those human beings who do not yet have the powers of rational autonomy (infants), or who have lost them (those with dementia), or who never had them (those with congenital mental impairment) are beneath human dignity? How far can a person go in the use of mood- and mind-altering drugs before rational autonomy is compromised? Are choices made under the influence of such drugs less than free? On such basic questions in bioethics Kant’s account of human dignity does not offer clear moral guidance.

Third, Kant’s moral philosophy has bequeathed to later ethical thought a deplorable legacy in the form of the rigid distinction between deontology and consequentialism, i.e., between a morality (such as Kant’s) of absolute imperatives and one (such as utilitarianism) that considers the good and bad results of our actions. Nowadays, if human dignity is invoked in the discussion of some bioethical issue, the first question that is usually raised is whether the term is being used as a categorical moral principle (e.g., “human cloning is wrong in principle, because it violates some inalienable right of the child”) or as an argument based on consequences (e.g., “human cloning is wrong because of the degrading effects it is likely to have on the child, the family, and society at large”). Bioethics in practice requires a healthy measure of old-fashioned prudence and is not well served by a dogmatic adherence to the artificial division between an ethics of principles and an ethics of consequences.

d. 20th century constitutions and international declarations: Finally, another prominent yet problematic source for the introduction of “human dignity” into contemporary bioethical discussions is the frequent use of that phrase in national constitutions and international declarations ratified in the aftermath of the Second World War. By proclaiming a belief in “human dignity”, such documents would seem, at first blush, to point beyond the prosaic safeguarding of “rights” advocated in the American founding (“life, liberty, and the pursuit of happiness”) or in the writings of John Locke (“life, liberty, and property”) and other modern natural right theorists.

The preamble to the Charter of the United Nations (1945) begins:

We the people of the United Nations, determined to save succeeding generations from the scourge of war, which twice in our lifetime has brought untold sorrow to mankind, and to reaffirm faith in fundamental human rights, in the dignity and worth of the human person, in the rights of men and women and of nations large and small…. [emphasis added]

In the Universal Declaration of Human Rights (1948), recognition “of the inherent dignity and of the equal and inalienable rights of all members of the human family” is said to be “the foundation of freedom, justice, and peace in the world.” At least thirty-seven national constitutions ratified since 1945 refer explicitly to human dignity, including the Basic Law (Grundgesetz) of Germany (1949), which begins: “Human dignity is inviolable. To respect and protect it is the duty of all state authority.”¹²

As Doron Shultziner has emphasized,¹³ while human dignity in these documents plays the role of a supreme value on which all human rights and duties are said to depend, the meaning, content, and foundations of human dignity are never explicitly defined. Instead, the affirmation of human dignity in these documents reflects a political consensus among groups that may well have quite different beliefs about what human dignity means, where it comes from, and what it entails. In effect, “human dignity” serves here as a placeholder for “whatever it is about human beings that entitles them to basic human rights and freedoms.” This practice makes a good deal of sense. After all, what mattered most after 1945 was not reaching agreement as to the theoretical foundations of human dignity but ensuring, as a practical matter, that the worst atrocities inflicted on large populations during the war (i.e., concentration camps, mass murder, slave labor), would not be repeated. In short, “the inviolability of human dignity” was enshrined in at least some of these documents chiefly in order to prevent a second Holocaust.

Yet because of its formal and indeterminate character, the notion of human dignity espoused in these constitutions and international declarations does not offer clear and unambiguous guidance in bioethical controversies.¹⁴ Certainly the fact that human dignity is mentioned prominently in these documents is to be welcomed as an invitation to explore the question, “What is the ground of human dignity?” And the sensible idea of invoking universal human dignity in order to establish a baseline of inviolable rights—in effect, a floor of decency beneath which no treatment of human beings should ever sink—may well prove to be of some value in holding the line against the most egregious abuses of the new biotechnologies (e.g., the deliberate creation of animal-human chimeras). Yet if we are content to regard human dignity as nothing more than an unspecified “Factor X”¹⁵ in virtue of which we are obliged to treat all persons with respect, then some bioethicists have wondered why we should bother invoking it at all. Why not dispense with dignity and simply spell out precisely what “respect for persons” demands of us? Ruth Macklin adopts this viewpoint, arguing that respect for persons is a sufficient principle for bioethics, one that entails “the need to obtain voluntary, informed consent; the requirement to protect confidentiality; and the need to avoid discrimination and abusive practices.”¹⁶ Her approach may have the virtue of simplicity, but it does not explain why all persons are entitled to respect;¹⁷ and it is far from clear that all present and future controversies in bioethics can be resolved merely by providing informed consent, honoring confidentiality, avoiding discrimination, and refraining from abuse.

e. Summary: To recapitulate the findings of this section: Important notions of human dignity are to be found both in classical antiquity and in Biblical scripture, each with lasting influence on modern thought. Yet the classical conception of dignity (in the general sense of human worth, grounded in excellence) is of problematic relevance to present-day bioethics, in part because of its ambiguous relationship to technological progress and in part because of its aristocratic and inegalitarian tendencies; while the specifically Stoic notion of human dignity is of limited use in bioethics both because of the severe and exacting standard it sets and because of the basic Stoic attitude of indifference to the external world, including the suffering of the body. And although the Biblical teachings on human dignity are rich and evocative, they have ambiguous implications for bioethics, pointing both toward godlike mastery of nature and toward humble acknowledgment of the sanctity of human life in all its forms. Turning to the modern era, both the moral philosophy of Kant and various constitutions and international declarations of the twentieth century appear to provide support for a belief in the equal dignity of all human beings. Yet Kant’s idea of human dignity carries certain theoretical baggage that limits its utility for bioethics, while the recently ratified constitutions and declarations tend to invoke dignity without clearly specifying either its ground or its content, suggesting that the concept itself might well be superfluous. On the other hand, it is hard to see how ethical standards for the treatment of human beings can be maintained without relying on some conception of what human beings are and what they therefore deserve.

3. Dignity understood as humanity—an indispensable concept for bioethics?

Having disentangled some of the roots of the modern concept of human dignity, can we make a compelling case for the usefulness of this concept in present-day and future bioethics? Only a tentative answer to this question can be hazarded here.

There is a strong temptation to say no, for the following reason. The fundamental question we have alluded to several times in this paper—the question of the specific excellence or dignity of man—has proved sufficiently daunting that a long line of great modern thinkers, from Hobbes and Locke to the American founders, have found it prudent, for political purposes, to assert that all human beings have rights and freedoms that must be respected equally, without spelling out too clearly the ground of that assertion.¹⁸ And such deliberate reticence as to the foundation and content of human dignity has arguably served liberal democracy well, fostering tolerance, freedom, equality, and peace. In the particular context of medical ethics, it must be acknowledged that for a long time the liberal principle of “respect for persons”—including the rights of voluntary, informed consent and confidentiality, as well as protection from discrimination and abuse—has proved serviceable in resolving many (though by no means all) ethical problems.

But in this extraordinary and unprecedented era of biotechnological progress, whose fruits we have scarcely begun to harvest, the campaign to conquer nature has at long last begun to turn inward toward human nature itself. In the coming decades we will increasingly acquire the power to isolate and modify the biological determinants of human attributes that hitherto have been all but immune to manipulation. For example, we are learning to control the development of human embryos in vitro, and this may one day make possible the cloning of human beings, the creation of animal-human chimeras, and the gestation of human fetuses in animal or artificial wombs. We are assembling a growing arsenal of psychoactive drugs that modulate not only behavior but also attention, memory, cognition, emotion, mood, personality, and other aspects of our inner life. We are acquiring the ability to screen out unwanted gene combinations in preimplantation embryos and may in future be capable of direct germline genetic modification. We may one day be able to modify the human genome so as to increase resistance to diseases, optimize height and weight, augment muscle strength, extend the lifespan, sharpen the senses, boost intelligence, adjust personality, and who knows what else. Some of these changes may amount to unobjectionable enhancements to our imperfect nature; but surely not all forms of biomedical engineering are equally benign and acceptable.

Our ever-increasing facility at tinkering with human nature itself poses an acute challenge to any easygoing agnosticism on the question of the ground and content of human dignity. As we become more and more adept at modifying human nature at will, it may well prove impossible to avoid a direct confrontation with the question posed by the Psalmist, “What is man that thou art mindful of him?” That is, among all the features of human nature susceptible to biotechnological enhancement, modification, or elimination, which ones are so essential to our humanity that they are rightly considered inviolable? For example, if gestation of fetuses in artificial wombs should become feasible, would it not be a severe distortion of our humanity and an affront to our dignity to develop assembly lines for the mass production of cloned human beings without mothers or fathers? Would it not be degrading to our humanity and an affront to human dignity to produce animal-human chimeras with some human features and some features of lower animals? Would it not be a corruption of our humanity and an affront to human dignity to modify the brain so as to make a person incapable of love, or of sympathy, or of curiosity, or even of selfishness?¹⁹

In short, the march of scientific progress that now promises to give us manipulative power over human nature itself—a coercive power mostly exercised, as C. S. Lewis presciently noted, by some men over other men, and especially by one generation over future generations²⁰ —will eventually compel us to take a stand on the meaning of human dignity, understood as our essential and inviolable humanity. If the necessity of taking that stand is today not yet widely appreciated, there will come a time when it surely will be. With luck, it will not be too late.

___________________________

References

18. Hobbes, however, was somewhat less reserved than the others: in chapter 13 of Leviathan (1651) he indicates that our equal rights are derived ultimately from our roughly equal ability to kill one another. Note that, for Hobbes, dignity is not intrinsic to human beings but is merely “the public worth of a man, which is the value set on him by the Commonwealth.” (Leviathan, ch 10).

19. In the novel White Noise (1985) by Don DeLillo, a drug is invented whose specific effect on the human brain is apparently to suppress the fear of death. Would it be compatible with human dignity for all of us to start taking such a drug?

20. C. S. Lewis, The Abolition of Man (Oxford: Oxford University Press, 1943), chapter 3: “From this point of view, what we call Man’s power over Nature turns out to be a power exercised by some men over other men with Nature as its instrument…. There neither is nor can be any simple increase of power on Man’s side. Each new power won by man is a power over man as well. Each advance leaves him weaker as well as stronger. In every victory, besides being the general who triumphs, he is also the prisoner who follows the triumphal car.”